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  <title>Downtime Form Template</title>
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<body class="c5">
  <p class="c0 title"><span class="c1">ClearCanvas RIS/PACS</span> <span class=
  "c1">-</span> <span class="c1">RIS Workflow Downtime Form</span></p>
  <hr>

  <h1 class="c0 c4"><span>A# <%= AccessionNumber %></span></h1>

  <h1 class="c0 c2"><span>Patient Information (Registration)</span></h1>

  <p class="c0 c3"></p>

  <p class="c0">
  <span>Surname:____________________________&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
  Given Name:___________________________________</span>
  </p>

  <p class="c0"><span>Date of Birth:________________________&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
  Sex: &nbsp; [ ] Male &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;[ ] Female</span>
  </p>

  <p class="c0">
  <span>Address:_______________________________________________________________________________</span></p>

  <p class="c0"><span>City:____________________________
  &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
  Province:______________________________________</span></p>

  <p class="c0"><br></p>
  <p class="c0"><span>Billing/Insurance information:</span></p>

  <p class="c0"><span>_______________________________________________________________________________________</span></p>

  <p class="c0"><span>_______________________________________________________________________________________</span></p>
  <p class="c0"><br></p>

  <p class="c0"><span>Ordering Practitioner:____________________________________________________________________</span></p>

  <p class="c0"><span>Imaging Service Requested:_______________________________________________________________</span></p>

  <h1 class="c0"><span>Technologist Documentation</span></h1>

  <p class="c0"><span>Modality/Room:________________________________________________________________________</span></p>
  
  <p class="c0"><span>Start time:_________________________________&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
  Stop time:_______________________________</span></p>

  <p class="c0"><span>Procedure(s) Performed:________________________________________________________________</span></p>
  
  <p class="c0"><span>Technologist Name:_____________________________________________________________________</span></p>

  <p class="c0"><br></p>
  <p class="c0"><span>Other comments:</span></p>

  <p class="c0">
  <span>_______________________________________________________________________________________</span></p>

  <p class="c0">
  <span>_______________________________________________________________________________________</span></p>

  <h1 class="c0"><span>Radiologist Report</span></h1>

  <p class="c0">
  <span>_______________________________________________________________________________________</span></p>

  <p class="c0">
  <span>_______________________________________________________________________________________</span></p>

  <p class="c0">
  <span>_______________________________________________________________________________________</span></p>

  <p class="c0">
  <span>_______________________________________________________________________________________</span></p>

  <p class="c0">
  <span>_______________________________________________________________________________________</span></p>

  <p class="c0">
  <span>_______________________________________________________________________________________</span></p>

  <p class="c0">
  <span>_______________________________________________________________________________________</span></p>

  <p class="c0"><br></p>
  <p class="c0"><span>Radiologist:____________________________________________</span></p>
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